BURLINGTON BOARD OF HEALTH
61 Center Street
Burlington, MA 01803
Tel: 781-270-1955 Fax: 781-273-7687
NOTIFICATION FORM FOR CATERERS
This form is to be completed by caterers who provide food for a catered event in the Town of Burlington as
required in 105 CMR 590.009(A): Minimum Sanitation Standards for Food Establishments State Sanitary
Code, Article X. A caterer means any person who prepares food intended for individual portion service,
transports and serves it at another location, or who prepares and serves food at a food establishment, other
than one for which he holds a permit, for service at single meal, party or similar gathering.
Name of Catering Business:
Street Address:
City, State, Zip:
Business Phone
Name of Business Owner(s):
Name of Person Completing Form:
Name of Event:
Event Location:
Date and Time of Event:
On Site Person in Charge (PIC):
Cell Phone of PIC:
Type of Event
(i.e,. wedding, baby shower, birthday, etc.)
IF YOU OPERATE A CATERING BUSINESS OUTSIDE OF BURLINGTON, PROVIDE A COPY
OF THE FOOD PERMIT OR LICENSE ISSUED TO THE CATERING BUSINESS FROM THE
TOWN, CITY OR STATE IN WHICH FOOD IS PREPARED. PLEASE MAIL OR FAX THIS
FORM AND A COPY OF THE PERMIT OR LICENSE TO THE BURLINGTON BOARD OF
HEALTH. CONTACT THE BURLINGTON BOARD OF HEALTH WITH ANY QUESTIONS.
Signature
Date